Affective Disorders
UWE RUHL
Institut für Psychologie, Universität Göttingen,
Göttingen, Germany
uruhl@uni-goettingen.de
Definition
In affective disorders, the fundamental disturbance is
a change in mood to depression (with or without associated
anxiety) or to elation (mania). The mood change
is usually accompanied by a change in the overall level
of activity; most of the other symptoms are either secondary
to, or easily understood in the context of, the
change in mood and activity. Most of these disorders
tend to be recurrent ( recurrent depressive disorder)
and the onset of individual episodes is often related to
stressful events or situations.
Basic Characteristics
Introduction
Hippocrates was one of the first to use the term “melancholy”,
literally meaning “black bile”, to describe
depressive symptoms. Usually, sadness accompanies
tragic situations; for example, the death of a loved one
or loss of employment. Everyone will experience such
sad phases during their lifespan and everyonewill experience
other common symptoms of depressive disorders
during times of stress; for example, problems with concentration,
sleep disturbances, and changes in appetite.
However, a depressive disorder differs both qualitatively
(e. g., much more pervasive) and quantitatively
(i. e., longer duration) from “normal” sadness or reactions
to stress. Thus, actual definitions of depressive
disorders (e. g. according to DSM-IV, ICD-10) define
a severity threshold (depending upon a specific number
of symptoms) and a minimum duration (2 weeks).
Major depression is associated with female gender,
lower social status, and stressful life events (e. g., hospitalization
for a serious illness, pregnancy, death of
a close relative, divorce). Depression can strike a person
at any age (Cave: even small children!). Major
Depressive Disorder (MDD) is very highly associated
with potential morbidity and mortality (suicide, medical
illness, disruption in interpersonal relationships,
substance abuse, and lost work time).
Dysthymia is a “chronic” form of depression. It is
defined by its subsyndromal nature (i. e., fewer than the
five persistent symptoms required to diagnose a major
depressive episode are present) and a protracted duration
of at least 2 years for adults. The symptoms of dysthymia
alone do not meet the criteria for Major Depression
and low mood is the primary symptom.
Patients with bipolar disorders ( bipolar affective disorder)
suffer from depressive episodes and/or manic/
hypomanic episodes (i. e., bipolar I and bipolar II disorders).
A manic syndrome is defined as a period of
unusual and extreme good mood or extreme irritability.
Manic patients often show a decreased need to sleep
and strong hyperactivity. Episodes of hypomania are
typical. Bipolar disorders are associated with significant
morbidity and mortality rates.
Cyclothymia is also marked by manic and depressive
states. Oscillation of high and lowmoods is typical.
However, those phases are neither of sufficient intensity
nor duration to merit a diagnosis of bipolar disorder or
MDD.
Epidemiology
Depressive disorders are more common in women than
in men (female/male ratio = 1.5–2/1). One year prevalence
rates of depression in European countries are estimated
between 1.9% (Netherlands and Great Britain;
Bijl et al. 1998; Jenkins et al. 1997) and 8.3% (Germany
Jacobi et al. 2004). Dysthymia affects about 2% of the
adult population per year; women seem to be slightly
more affected than men. The one year prevalence estimate
of bipolar disorders in adults is 0.9% (Pini et al.
2005). Almost 2% of the adult population suffers from
bipolar disorders (i. e., lifetime prevalence, Kessler et
al. 1994). Because the costs in existing economic studies
are based on a top-down approach (and depend on
assumptions in terms of resource use), it is impossible
to assess the exact economic burden. Depressive disorders
have a high economic burden due to their high
prevalence and their association with high disability in
acute depressive phases (e. g., lost workdays, reduced
working capacity). Unipolar major depression is one
of the 10 leading diseases of the global disease burden
(Lopez et al. 2006).
Pathophysiology/Etiology
The pathophysiology of MDD has not been clearly
defined. Different studies have suggested a disturbance
in CNS serotonin (i. e., 5-HT). Norepinephrine (NE)
and dopamine (DA) are other important neurotransmitters
forMDD (“monoamine hypothesis”). However,
this hypothesis is not sufficient to explain the complex
symptoms of depression. One problem is that many
other neurotransmitter systems are altered in depressive
disorders (e. g., GABA and acetylcholine). Another
problem is that improvement of monoamine neurotransmission
with medication and lifting of the clinical
signs of depression do not prove that depression is actually
caused by defective monoamine neurotransmission.
Accordingly, in different studies, no objective biological
markers exist that correspond definitively with
the disease states of bipolar disorder ( bipolar affective
disorder), dysthymia, and cyclothymia. Overall,
the etiology of affective disorders is multimodal
(e. g., biological factors, psychosocial factors, stressful
life events) with a strong genetic component.
Consequences
The relationship between depressive disorders and
comorbidity of other mental disorders (especially anxiety
disorders, i. e. generalized anxiety disorders, panic, agoraphobia, and post-traumatic stress
disorders) as well as physical illness is well established.
Patients suffering from bipolar disorders frequently
showcomorbid anxiety disorders and substance use disorders.
Accordingly, dysthymic disorders are associated
with higher rates of comorbid substance abuse. Suicide
is the most severe complication of major depression.
Depressive disorders account for about 20 to 35%
of all deaths by suicide (Angst et al. 1999). Men are
much more likely to succeed in committing suicide than
women (ratio about 4:1). However, women attempt
suicide about four times more often than men.
Treatment
Antidepressant medication and/or cognitive-behavioral
psychotherapy have the strongest evidence for the
treatment of depressive disorders. In severe depressions
(with or without psychotic symptoms), patients
are mostly treated with antidepressants and cognitivebehavioral
psychotherapy. Antidepressants should be
changed if there is no clear effect (after an additional
attempt of dose increase) within 4 to 6 weeks.
Accordingly, revisions to a psychotherapeutic treatment
plan should be considered, including the addition of
antidepressant medication, if there is no symptomatic
improvement within 3 or 4 months of therapy. Further,
to reduce relapse rates, anti-depressive medication
should be used routinely for at least 6 months after
remission (i. e., continuation phase therapy). Cognitivebehavioral
psychotherapy is also important for relapse
prophylaxis. In recurrent depressive patients ( recurrent
depressive disorder), either antidepressants or special
medication for relapse prophylaxis and mood stabilization,
respectively (e. g., lithium, valproate), may
be used for years (i. e., maintenance phase therapy).
Such maintenance pharmacotherapy is typically recommended
for individuals with a history of three or more
depressive episodes, chronic depression, or bipolar
disorder.
Cross-References
Depressive Episode
Dysthymia
Hypomania
Mania
Recurrent Depressive Disorder
References
Angst J, Angst F, Stassen HH (1999) Suicide risk in patients with
major depressive disorder. J Clin Psychiatry 60:57–62
Bijl RV, van Zessen G, Ravelli A (1998) Prevalence of psychiatric
disorder in the general population: results of the Netherlands
Mental Halth Survey and incidence Study (NEMESIS). Soc
Psychiatry Psychiatr Epidemiol 33:587–95
Jacobi F, Wittchen HU, Hölting C, Höfler M, Pfister H, Müller
N, Lieb R (2004) Prevalence, comorbidity and correlates of
mental disorders in the general population: results from the
German Health Interview and Examination Survey (GHS).
Psychol Med 27:775–789
Jenkins R, Leweis G, Bebbington P, Brugha T, Farrell M, Gill B,
Meltzer H (1997) The national psychiatric morbidity surveys
of Great Britain: initial findings from the household survey.
Psychol Med 27:775–89
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M,
Eshleman S, Wittchen HU, Kendler KS (1994) Lifetime and
12-month prevalence of DSM-III-R psychiatric disorders in
the United States. Results from the National Comorbidity
Survey. Arch Gen Psychiatry 51:8–19
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ
(2006) Global and regional burden of disease and risk factors
2001: systematic analysis of population health data. Lancet
367:1747–57
Pini S, de Queiroz V, Pagnin D, Pezawas L, Angst J, Cassano
GB, Wittchen HU (2005) Prevalence and burden of bipolar
disorders in European countries. Eur J Neuropsychopharmacol
15:425–34
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